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School/Preschool Supportive Health Services

Medicaid-in-Education OverviewMedicaid 101

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MEDICAID-101 TRAINING TOPICS

• Billing Requirements

• Student Demographics

• Documentation Requirements

• Claiming Process

• Reports

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Billing Requirements

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What are the requirements for billing?

• District/County/§4201 school must have a Medicaid provider number and a

Federal NPI Number

• Student must be eligible for Medicaid (have an eligible CIN)

• District/County/§4201 schools must obtain parental consent (in accordance

with IDEA) prior to billing Medicaid

• District/County/§4201 schools must incur a cost for the service and/or

evaluation

• Evaluations: student must have been officially referred to CSE/CPSE

• Student must be referred and/or classified as a student with a disability

• Delivery of services must be documented

• Services/evaluations delivered by appropriately credentialed provider

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What services and evaluations are reimbursable? SERVICES:– Speech Therapy– Physical Therapy– Occupational Therapy– Psychological Counseling (pended)– Nursing

EVALUATIONS:– Psychological -basic (pended)– Comprehensive Psychological with social history (pended)– Medical– Specialist Medical– Audiological

SPECIAL TRANSPORTATION:- Special transportation provided to eligible students as listed on the IEP

TARGETED CASEMANAGEMENT (schoolage only)

- IEP Reviews- Ongoing Service Coordination

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Student Demographics

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How is the demographic information processed?

When student is referred to CSE/CPSE

• District/County/§4201 schools must obtain parental

consent (in accordance with IDEA)

Enter demographics onto your local computer software

– Name (First and Last)

– Date of Birth

– Gender

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Create Electronic Demographic File

The SD/County/§4201 Schools will create and submit a Medicaid Demographic (MD) file, using Medicaid software, to CNYRIC via the internet/e-mail/FTP or MEDweb site.

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CNYRIC processes your demographic information and matches for Medicaid eligibility.

The eligibility information is posted on the CNYRIC Website in your monthly Medicaid Eligibility (ME) file (ELIGDATA).

Each month the SD/County/§4201 schools would need to update their students’ Medicaid eligibility information by downloading the ELIGDATA file to their local computer.

Matching Process

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Matching Process Eligibility Reports and Files

These reports and files are now available on the CNY-Web Report site and your RIC will provide training on access and interpretation.

• Medicaid Eligibility Report (ELIGREPT) lists your students with a CIN

• Medicaid Eligibility (ME) File (ELIGDATA) must be downloaded onto your local computer

• Non-Matching Reports (MATCH):– Near-Match - possible matches– Multiple Match – must select correct CIN and reenter– Match Not Found – no CIN match identified

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Matching Process Eligibility Reports and Files (con’t)

These reports and files are now available on the CNY-Web Report site and your RIC will provide training on access and interpretation.

• Biographical Reports:– Delete Unmatched Students (BIODLTE) - students w/o a

CIN – Inactivated Students (BIOINCT) - students w/CIN but not

claimed • Transaction (BIOUPDT):

– Error Report - lists problems with the biographic data you submitted

– Update Report – lists accepted adjustments (ADD/CHG/DEL)

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DocumentationRequirements

see handout

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What EVALUATION documentation is required?

• Referral to the CSE/CPSE• Signed/Dated copy of Evaluation• Medical Referral (for a formal Speech,

Specialist Medical, Audiological Evaluation)• Professional Licenses & Certifications• When necessary, a Provider Agreement &

Statement of Reassignment are required

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Who can complete a medical referral for an evaluation?

• SpeechPhysician, Physician Assistant, Nurse Practitioner,

NYS Licensed and Registered Speech Language Pathologist

• Specialist MedicalPhysician, Physician Assistant, Nurse Practitioner

• AudiologicalPhysician, Physician Assistant, Nurse Practitioner

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When must a medical referral be completed?

Every time a ‘Formal’ Evaluation is needed.

The medical referral must be signed/dated and can be in a list format (can contain more than one student) .

Note - A ‘formal’ evaluation for Speech, Specialist Medical and Audiological requires parental permission.

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What SERVICE documentation is required?

• An IEP* (that covers the service period)

• Medical recommendation (order) for Services- (for Speech, OT, PT, & Nursing before

beginning services)

• Provider Service Sheets* (date specific, signed/dated) • Progress Notes* (that cover the billed period) must be signed and dated by service provider

*electronic or paper format is acceptable

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What SERVICE documentation is required (con’t)?

• Professional Licenses and Certifications

• Speech-”Under the Direction Of” (UDO) proof

• The Nature of Special Transportation on IEP

• When necessary, a Provider Agreement & Statement of Reassignment is required

• TCM-Ongoing Service Coordination contact sheets

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Who can complete a medical recommendation (order) for services?

• SpeechPhysician, Physician Assistant, Nurse Practitioner,

NYS Licensed and Registered Speech Language Pathologist

• Physical TherapyPhysician, Physician Assistant, Nurse Practitioner

• Occupational Therapy Physician, Physician Assistant, Nurse Practitioner

• Skilled Nursing ServicePhysician, Physician Assistant, Nurse Practitioner

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A Medical Recommendation (Order) for Services

• Must be signed/dated by an appropriate professional.

• Must be child specific

• Must either include frequency and duration

or include the phrase “as indicated on IEP”

• Is good for the life of the referenced IEP

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Why is “Under the Direction of” for Speech Services necessary?

SED requires that speech services must be provided by teacher of speech and hearing handicapped (TSHH) or teacher of students with speech and language disabilities (TSSLD)

Medicaid regulations require that speech services must be provided by NYS Licensed and Registered Speech Language Pathologist

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What is the responsibility of the speech pathologist?

• Assures services scheduled as indicated on IEP

• Assures services are medically appropriate

see handout-365A

• Accessible to TSHH and TSSLD

• Reviews progress notes

(see handout-May 23, 2003 SED ltr)

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What documentation is needed for “Under the Direction of”?

• Certification for “UDO” and accessibility

- A list of TSHHs and TSSLDs

- How accessibility will be provided

- Dated signature of Speech Language Pathologist (SLP), w/title

Note – This sheet must be updated when there is a change in personnel (see handout)

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Documentation Needed for “Under the Direction Of” (con’t)

•Documentation must exist that would support the IEP, Student Service schedule, and Progress Notes have been reviewed by the SLP

•February 6, 2007 Theresa Savo Letter (see handout)

•Face to face contact (SLP and student) - at the beginning of treatment and periodically thereafter

(If TSHH/TSSLD is also an SLP, see handout-6/03 SED ltr)

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Documentation Needed for “Under the Direction Of” (con’t)

• SLP must be familiar with student’s treatment plan• SLP assumes responsibility for services• SLP must provide adequate supervisory direction to

teacher• Regularly scheduled meetings and phone contacts

must be documented• Accessibility must be documented per occurrence• All documentation must be signed/initialed and dated

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Who must have a copy of the certification for “Under the Direction

of” and accessibility?

School District

TSHH/TSSLD

NYS Licensed and Registered Speech Pathologist

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Psychological Counseling Service

Billing for Psychological Counseling Services is pended until further notice.

• Documentation required for psychological counseling services:

1. Must be on the IEP.2. Quarterly Progress Notes, signed and dated.3. Monthly Service Report, signed and dated.4. Service must be provided by licensed professional

(certification alone is not sufficient)- Professional titles will be determined at a later date

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PHYSICAL THERAPY & OCCUPATIONAL THERAPY

• Documentation required:– Must be on the IEP with Frequency & Duration.– Appropriate Credential of the Licensed and Registered

Therapist.– Medical Recommendation (Order) for service, Signed

and Dated. – Quarterly Progress Notes – Signed and Dated.– Monthly Service Report indicating Attendance, Signed

and Dated by the Therapist.– All of the above required when supervising a PTA or

OTA.

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Additional Supervision Requirements for Physical Therapy Assistant

• Documentation required for Supervision:1. Licensed PT sets all Goals and establishes a plan of care

& determines whether the student is appropriate to receive care from a PTA.

2. Initial joint visit between the student, the Lic. PT and the PTA.

3. Periodic Treatment of the Student by the Lic. PT as indicated in the Plan of Care. Must occur every sixth visit or every 30 days, whichever occurs first.

4. The performance appraisals and evaluations of the PTAs.5. All documents must be signed and dated by the Lic. PT. see Article 136

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Additional Supervision Requirements for

Occupational Therapist Assistants • The Licensed Occupational Therapist must sign and

Date:1. The Treatment Plan

2. The evaluations and assessment documents that are used to determine the method of treatment.

3. The weekly service notes after reviewing

4. The performance appraisals and evaluations of the OTAs,

see Article 156

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Nursing Services

• Documentation Requirements:1. Must be on the IEP2. Medical Recommendation for the Service.3. Monthly service report in 15 minute segments.4. Health Care Plan if appropriate.5. Health Care Protocols if appropriate.6. All services must be provided in accordance with the

Nurse Practice Act.7. Only acceptable credential is Registered Nurse“RN” or a

Licensed Practical Nurse “LPN” under the supervision of an “RN”.

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• As defined in the SED March, 2005 Rebecca Cort memo (see handout)– Must be included in the IEP – The Nature of Spec. Trans. must be documented on the IEP– Can only be claimed for a round trip on a day of

Medicaid reimbursable service

- School bus rosters (schedules)- Bus logs (attendance)- Service delivery documents

Special Transportation

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What Targeted Case Management (TCM) documentation is required?• Referral to the CSE• The IEP and/or CSE meeting notes (with the meeting type clearly labeled)

– Initial Review– Annual Review– Triennial Review (Reevaluation)– Amended/Requested Review

• Ongoing Service Coordination (OSC) - contact notes

• Note: TCM is not billable for preschool students

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Ongoing Service Coordination

• Must be discussed at CSE meeting.

• The service coordinator or case manager must document at least two contacts per month relating to service coordination or case management in order to bill Medicaid

• The contact notes* (see handout) will serve as documentation for billing Medicaid.

• District must be preapproved to bill for OSC

*Must identify who was contacted, when and include issue, action, summary of the contact then the sheet must be signed/dated by the coordinator.

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Retention of Documentation

Per January, 2002 Richard Cate letter (see handout):

All documentation must be retained

until further notice!

The School District/County/§4201 School officials are responsible for and should have formal written policy regarding compliance of all documentation requirements.

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Claiming Process

(see handout)

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Claiming Services and Evaluations

• SD/County/§4201 Schools collect:– Monthly/Annual Service Provider Sheets– School-age documentation for Targeted Case

Management

• SD/County/§4201 Schools enter service dates/evaluation completion dates and completed Targeted Case Management review dates (SD/§4201 Schools only) onto their Medicaid billing software

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Processing of Claim Data

SD/County/§4201 Schools submit claiming files to

CNYRIC

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To determine when claims should be submitted to CNYRIC and when checks should arrive

Your Business Office should be notified as to when a claim has been submitted, the amount of the claim and when to expect the (SED & DOH) checks

2010 Claiming Calendar (see handout)

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Review Service Reports/Files

• Service Update Report (SRVUPDT)– Accepted claims– Rejected claims– Held Claims

• Billing Summary Report– Claims forwarded to CSC for processing (BILLSUM)– Non-Billed Report-lists rejected billing (NONBILL)

• Remittance Report (REMIT)– Paid – Denied– Pended

• Remittance File (MR File) (RMITDATA)

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Management Reports

• CNYRIC SERVNOS Report (SRVNDIST)– Generated quarterly by CNYRIC

(March, June, September, December)

– A two year listing of claims submitted for each individual student, by month/service

– DOH - Summary of Paid Claims – For all SD within a designated RIC– Individual, for each SD/County/§4201 School

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Medicaid in EducationCNYRIC-Web Report Internet Access

You will now be able to access your SD/County/§4201 School reports at anytime via the internet on the CNYRIC Website at http://www.cnyric.org under ‘Web Applications’, in the ‘Web Reports’

Please contact your RIC for password authorization procedures and Web access training.

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Websites• Medicaid-in-Education homepage: http://www.oms.nysed.gov/medicaid/• Office of Professions homepage: http://www.op.nysed.gov • National Alliance for Medicaid in Education http://medicaidforeducation.org/

• LEAnet http://www.theleanet.com/

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SED Contact Listing

SED:Harold Matott hmatott@mail.nysed.gov

518-486-1979Steven Wright swright2@mail.nysed.gov

518-486-4887Kelly Gicobbi kgicobbi@mail.nysed.gov

518-486-7828

http://www.oms.nysed.gov/medicaid/contacts/State_Medicaid_Contacts.htm